Presentation is loading. Please wait.

Presentation is loading. Please wait.

Angular deformities of LL: –Bow legs. –Knock knees. Rotational deformities of LL: –In-toeing. –Ex-toeing. Leg aches. CDH. Feet problems. Irritable hip.

Similar presentations


Presentation on theme: "Angular deformities of LL: –Bow legs. –Knock knees. Rotational deformities of LL: –In-toeing. –Ex-toeing. Leg aches. CDH. Feet problems. Irritable hip."— Presentation transcript:

1 Angular deformities of LL: –Bow legs. –Knock knees. Rotational deformities of LL: –In-toeing. –Ex-toeing. Leg aches. CDH. Feet problems. Irritable hip. Common Orthopedic Problems in Children

2 Angular LL Deformities of LL

3 Angular Deformities Nomenclature Bow legsKnock knees Genu Varus Genu Valgus

4 Angular Deformities Range of Normal Varies With Age During first year : Lateral bowing of Tibiae During second year : Bow legs (knees & tibiae) Between 3 – 4 years : Knock knees

5 Angular Deformities Evaluation Should differentiate between “physiologic” and “pathologic” deformities

6 Angular Deformities Evaluation PhysiologicPathologic Expected for age Generalized Regressive Mild – moderate Symmetrical Not expected for age Localized Progressive Severe Asymmetrical

7 Angular Deformities Causes PhysiologicPathologic - Use of walker? - Early wt. bearing - Overweight Exaggerated : Normal – for age Idiopathic Injury to Epiphys. Plate Infection / Trauma Metabolic disease Endocrine disturbance Rickets

8 Angular Deformities Evaluation Symmetrical deformity

9 Angular Deformities Evaluation Asymmetrical Deformity

10 Angular Deformities Evaluation Generalized deformity

11 Angular Deformities Evaluation Localized deformity Blount’s

12 Angular Deformities Evaluation Rickets Localized deformity

13 in bow legs / genu varum Inter-condylar distance Measure Angulation ( standing / supine ) Angular Deformities Evaluation

14 in knock knees /genu valgum Inter- malleolar distance Measure Angulation ( standing / supine ) Angular Deformities Evaluation

15 Measure Angulation Angular Deformities Evaluation Use goneometer measures angles directly

16 Serum Calcium / Phosphorous ? Serum Alkaline Phosphatase Serum Creatinine / Urea – Renal function Angular Deformities Evaluation Investigations / Laboratory

17 X-ray when severe or possibly pathologic Standing AP film –long film ( hips to ankles ) with patellae directed forwards Look for diseases : –Rickets / Tibia vara (Blount’s) / Epiphyseal injury.. –Measure angles. Angular Deformities Evaluation Investigations / Radiological

18 Femoral-Tibial AxisMedial Physeal Slope Angular Deformities Evaluation Investigations / Radiological

19 Angular Deformities When To Refer ? Pathologic deformities: Asymmetrical. Localized. Progressive. Not expected for age. Exaggerated physiologic deformities: Definition ?

20 Angular Deformities Surgery

21

22 Rotational LL Deformities Frequently seen. Concerns parents. Frequently prompts varieties of treatment. ( often un-necessary / incorrect ) In-toeing / Ex-toeing

23 Rotational Deformities Level of affection : Femur Tibia Foot

24 Rotational Deformities Femur Ante-version = more medial rotation Retro-version = more lateral rotation

25 Rotational Deformities Normal Development Femur : Ante-version : –30 degrees at birth. –10 degrees at maturity. Tibia : Lateral rotation : –5 degrees at birth. –15 degrees at maturity.

26 Rotational Deformities Normal Development Both Femur and Tibia laterally rotate with growth in children Medial Tibial torsion and Femoral ante-version improve ( reduce ) with time. Lateral Tibial torsion usually worsens with growth.

27 Rotational Deformities Clinical Examination Rotational Profile At which level is the rotational deformity? How severe is the rotational deformity? Four components: 1- Foot propagation angle. 2- Assess femoral rotational arc. 3- Assess tibial rotational arc. 4- Foot assessment.

28 Rotational Deformities Clinical Examination Rotational Profile 1- Foot propagation angle – Walking Normal Range: +10 o _ 10 o ? In Eastern Societies +25 o _ 10 o

29 Rotational Deformities Clinical Examination Rotational Profile 2- Assess Femoral Rotational Arc Supine Extended

30 Rotational Deformities Clinical Examination Rotational Profile 2- Assess Femoral Rotational Arc Supine flexed

31 Rotational Deformities Clinical Examination Rotational Profile 3- Tibial Rotational Arc Thigh-foot angle in prone foot position is critical leave to fall into natural position

32 Rotational Deformities Clinical Examination Rotational Profile 4- Foot assessment Metatarsus adductus Searching big toe Everted foot Flat foot

33 Out-toeing : Normal seen when infant positioned upright ( usually hips laterally rotate in-utero ) Metatarsus adductus : medial deviation of forefoot 90 % resolve spontaneously casting if rigid or persists late in 1st year Rotational Deformities Common Presentations Infants

34 Rotational Deformities Common Presentations Toddlers In-toeing most common during second year. ( at beginning of walking ) Causes : – medial tibial torsion. –metatarsus adductus. –abducted great toe.

35 Rotational Deformities Common Presentations Toddlers - Medial Tibial Torsion The commonest cause of in-toeing Observational management is best Avoid special shoes / splints / braces – unnecessary, ineffective, interferes with activity and cause psychological and behavioral problems.

36 Rotational Deformities Common Presentations Serial casting is effective in this age-group Usually correctable by casting up to 4 years Toddler - Metatarsus Adductus

37 Rotational Deformities Common Presentations Dynamic deformity Over-pull of Abductor Hallucis Muscle during stance phase Toddlers - Abducted Great Toe Spontaneously resolve - no treatment

38 Rotational Deformities Common Presentations Child In-toeing : due to medial femoral torsion Out-toeing : in late childhood lateral femoral / tibial torsion

39 Rotational Deformities Common Presentations Child Medial Femoral Torsion Usually: - starts at years, - peaks at 4 – 6 years, - then resolves spontaneously. Girls > boys. Look at relatives - family history – normal. Treatment usually not recommended. If persists > 8 years and severe, may need surgery.

40 Rotational Deformities Common Presentation Stands with knees medially rotated (kissing patellae). Sits in W position. Runs awkwardly (egg-beater). Family History Medial Femoral Torsion (Ante-version)

41 Rotational Deformities Common Presentations Child Lateral Tibial Torsion Usually worsens. May be associated with knee pain (patellar) specially if LTT is associated with MFT. ( knee medially rotated and ankle laterally rotated )

42 Rotational Deformities Common Presentations Child Medial Tibial Torsion Less common than LTT in older child May need surgery if : –persists > 8 year, –and causes functional disability

43 Rotational Deformities Management Challenge : dealing effectively with family In-toeing : spontaneously corrects in vast majority of children as LL externally rotates with growth - Best Wait !

44 Rotational Deformities Management Convince family that only observation is appropriate < 1 % of femoral & tibial torsional deformities fail to resolve and may require surgery in late childhood.

45 Rotational Deformities Management Attempts to control child’s walking, sitting and sleeping positions is impossible and ineffective cause frustration and conflicts. She wedges and inserts : ineffective. Bracing with twisters :ineffective - and limits activity. Night splints : better tolerated - ? Benefit.

46 Rotational Deformities Management Shoe wedges IneffectiveTwister cables Ineffective

47 Rotational Deformities When To Refer ? Severe & persistent deformity. Age > 8-10y. Causing a functional dysability. Progressive.

48 Rotational Deformities Management When Is Surgery Indicated ? In older child ( > 8 – 10 years ). Significant functional disability. Not prophylactic !

49 Leg Aches / Growing Pains

50 Incidence : % of children. More In girls / At night / In LL. Diagnosis is made by exclusion.

51 Leg Aches / Growing Pains History Vague pain. Poorly localised. Bilateral. Nocturnal. Seldom alters activity. Long duration.

52 Leg Aches / Growing Pains Examination General health is normal. No deformities. No joint stiffness. No tenderness. Normal gait. No limping.

53 Leg Aches / Growing Pains Management When atypical history or signs present on examination: –Imaging and lab. Studies. If all negative : –Symptomatic treatment : Heat / Analgesics. –Reassure family : Benign. Self-limiting. Advise to re-evaluate if clinical features change.

54 Leg Aches / Growing Pains FeatureGrowing PainSerious Problem History : Long durationOftenUsually not Pain localisedNoOften Pain bilateralOftenUnusual Ulters activityNoOften Cause limpingNoSometimes General healthGoodMay be ill From Stahili : Practice of Pediatric Orthopedics 2001

55 Leg Aches / Growing Pains FeatureGrowing PainSerious Problem Physical examination : TendernessNoMay show GuardingNoMay show Reduced rang of motionNoMay show Laboratory : CBCNormal? Abnormal ESRNormal? Abnormal From Stahili : Practice of Pediatric Orthopedics 2001

56

57

58 CDH / DDH Congenital Dislocation of Hip. Developmental Dysplasia of Hip.

59 CDH Spectrum Teratologic Hip : Fixed dislocation Often with other anomalies Dislocated Hip : Completely out May or may not be reducible Subluxated Hip : Only partially in Unstable Hip : Femoral head can be dislocated Acetabular Dysplasia : Shallow Acetabulum Head Subluxated or in place

60 CDH Etiology & Risk Factors Prenatal : –Positive family history (increases risk 10X) –Primi-gravida –Female (4-6 X > Males) –Oligo-hydramnious –Breech position (increases risk 5-10 X) Postnatal : –Swaddling / Strapping ( ? Knees extended) –Ligament Laxity –Torticollis (CDH in % cases) –Cong. Knee recurvatum / dislocation –Metatarsus adductus / calcaneo-valgus

61 CDH Risk Factors When Risk Factors Are Present The infant should be examined repeatedly The hip should be imaged by –U/S –or X-ray

62 CDH Clinical Examination

63 CDH Neonatal Examination LOOK : Asymmetric thigh folds –Posterior –anterior

64 CDH Clinical Examination Look : Shortening ( not in neonates ) - Galeazzy sign - in supine

65 CDH Neonatal Examination MOVE : Hip instability in early infancy Limited hip abduction in flexion - later (careful in bilateral) if <60 0 on both sides: request imaging

66 CDH Neonatal Examination

67 CDH Neonatal Examination Hip Flexion Deformity SPECIAL : Loss of fixed flexion deformity of hips in early infancy. Normally FFD: –newborn 28 o –at 6 weeks 19 o –at 6 months 7 o Normal FFD CDH No FFD Thomas Test

68 CDH Neonatal Examination Ortolani Barlow Feel Clunk Not hear click !

69 CDH Neonatal Examination Ortolani / Barlow clunk OrtolaniBarlow

70 CDH Neonatal Examination Ortolani TestBarlow Test

71 CDH Clinical Examination Hip clicks : - fine, short duration, high pitched sounds - common and benign – from soft tissues Hip clunks : - sensation of the hip displacing over the acetabular margin If in doubt : U/S in young infants single radiograph if > 2-3 months

72 CDH Clinical Examination Neonate (up to 2-3 months) : –Instability/ Ortolani-Barlow Infant ( > 2-3 months) : –Limited abduction –Shortening ( Galeazzi ) Toddler : –Limited abduction –Shortening ( Galeazzi ) Walker : –Trendelenburgh limpimg

73 CDH Ultrasound Screening Early U/S screening not recommended Delayed U/S screening : –Older than 3 weeks –Those at risk or suspicious by: History Clinical exam

74 CDH Treatment Birth to 6 months : –Pavlik harness or hip spica cast 6 months – 12 months : –closed reduction UGA and hip spica casts 12 months – 18 months : –possible closed / possible open reduction Above 18 months : –open reduction and ? Acetabuloplasty Above 2 years : –open reduction,acetabulplasty, and femoral osteotomy

75 CDH Treatment Method depends on Age The earlier started, the easier the treatment & the better the results Should be detected EARLY UREGENT referral once an abnormality is detected.

76


Download ppt "Angular deformities of LL: –Bow legs. –Knock knees. Rotational deformities of LL: –In-toeing. –Ex-toeing. Leg aches. CDH. Feet problems. Irritable hip."

Similar presentations


Ads by Google